AIDS (Acquired Immune Deficiency Syndrome, AIDS) is the most serious immunosuppressive clinical syndrome caused by human immunodeficiency virus infection, HIV mainly destroys CD4+ T cells, when CD4+ T cells are reduced to less than 200/ul due to immune deficiency and various opportunistic infections occur, common infections These include lung infections, neurological disorders, retinitis, etc.
HIV-associated ophthalmopathy is a common complication of AIDS, affecting 50-75% of HIV-infected patients worldwide. HIV-associated ophthalmopathy can affect all tissues of the eye, usually producing blurred vision, decreased visual acuity, floaters in front of the eyes, and even blindness. HIV-associated ophthalmopathy includes non-infectious retinitis, such as HIV microangiopathy, or absorbent cotton spots; it also includes retinitis due to infectious factors, such as The incidence of HIV-associated ophthalmopathy varies by geographic region, with sub-Saharan Africa having a lower incidence of HIV-associated ophthalmopathy compared to developed countries, with the literature reporting a 1% incidence of CMV retinitis in patients with HIV in Malawi. CMV retinitis was found in 1% of Malawian patients and HIV microangiopathy in 13% of patients; Sophia et al. reported HIV-related ophthalmopathy in 23.8% of Indian AIDS patients.
Since 1985, when the first AIDS case was identified in China, 22,000 AIDS patients have died. Since 1995, there has been a rapid increase in the number of HIV/AIDS patients in China, and HIV-associated ophthalmopathy, especially CMV retinitis, which leads to vision loss and even irreversible blindness, poses a serious risk to patients. Beijing Ditan Hospital is a center for the diagnosis and treatment of HIV and its opportunistic infections, and our ophthalmology department has adopted fundoscopy for HIV patients to improve the diagnosis rate of HIV-related eye disease. In order to improve the diagnosis of HIV-related ophthalmology by clinicians, this article initially explores the clinical and epidemiological features of HIV-related ophthalmology in combination with AIDS.
Subjects and methods.
1. Diagnostic criteria for AIDS and HIV-related ophthalmopathy: AIDS diagnostic criteria refer to the 2006 AIDS Diagnostic Guidelines developed by the AIDS Group of the Infectious Diseases Branch of the Chinese Medical Association.
HIV-related ophthalmology includes non-infectious retinitis, such as HIV microangiopathy, i.e. absorbent cotton spots; it also includes retinitis due to infectious factors, such as retinitis due to cytomegalovirus and other infections; and CMV retinitis following immune reconstitution syndrome after HAART treatment.
In this study, we retrospectively studied the clinical data and ophthalmology consultation records of 92 AIDS patients hospitalized in Beijing Ditan Hospital from October 2008 to February 2010. All 92 patients underwent ophthalmology consultation after admission regardless of the presence or absence of ophthalmic symptoms or CD4 levels.
2. Clinical data: Among the 92 patients, we mainly focused on the patients’ gender, age, epidemiological history, clinical stage of AIDS, CD4+ T-cell level, and the presence of tuberculosis inside and outside the lung, and ophthalmic symptoms mainly focused on floating objects in front of the eyes, blurred vision, decreased vision, and blindness. In addition, we also focused on other opportunistic pathogenic infections or tumors of the respiratory system, digestive system, nervous system, and eyes in 92 AIDS patients. The above information was used to create a database through Excel software.
3. Laboratory and physical examinations: Blood was drawn for T-cell subsets on admission in 92 patients. This laboratory test mainly reflected the level of cellular immunity of the body, with particular attention to the CD4+ T-cell count; CMV pp65 antigen and CMV-DNA quantitative tests were detected. For those with neurological symptoms, cerebrospinal fluid examination and cranial CT were completed to clarify neurological lesions.
4. Ophthalmologic examination: 92 patients underwent ophthalmologic consultation after admission regardless of the presence of ophthalmic symptoms or CD4 level, and improved visual acuity and visual acuity examination of both eyes, fundoscopic examination to clarify retinal lesions, and slit lamp examination of the anterior pole of the eye.
5. Statistical analysis: χ2 test or t-test was performed for the proportion of gender, epidemiological history, proportion of tuberculosis, proportion of ophthalmic symptoms, mean age, and mean CD4+ count of patients with or without HIV-related ophthalmopathy using the statistical analysis software SPSS 12.0.
Results.
I. Case characteristics.
From October 2008 to February 2010, 92 AIDS patients hospitalized at Beijing Ditan Hospital underwent ophthalmologic examination. 92 patients had a mean age of 43 years, including 79.3% of males, and the proportions of epidemiologic history of HIV transmission through homosexuality, heterosexuality, and blood transfusion were 14.1%, 52.2%, and 33.7%, respectively. 28 patients (30.4%) had pulmonary 28 patients (30.4%) had internal and external tuberculosis; all 92 patients were in stage 4 of AIDS.
II. Ophthalmic manifestations.
According to the literature, HIV-associated ophthalmopathy mainly refers to retinitis due to HIV-associated microangiopathy, infectious factors and immune reconstitution. 92 patients had complete ophthalmologic examination, and all patients were divided into those with and without HIV-associated ophthalmopathy, 50 in the former and 42 in the latter. In the group with HIV-associated ophthalmopathy, 56% had ophthalmic symptoms such as decreased vision/floaters and 44% had no ophthalmic symptoms; in the group without HIV-associated ophthalmopathy, 46.5% had ophthalmic symptoms and 47.6% had no ophthalmic symptoms, and the difference was not significant.
In the groups with and without HIV-associated ophthalmopathy, the mean CD4 levels were 87/ul and 224/ul, respectively, and the differences were significant; 66% and 33.2% of patients with CD4 levels below 50/ul in the two groups, respectively, and the differences were significant, suggesting that HIV-associated ophthalmopathy is associated with high or low CD4 levels, especially CD4 levels below 50 cells/ul.
In the groups with and without HIV-associated ophthalmopathy, 30% and 30.9% of the patients had tuberculosis, respectively, and the differences were not significant, suggesting that HIV-associated ophthalmopathy was not related to the presence or absence of tuberculosis.
Among the 92 patients with AIDS, HIV microangiopathy, i.e., absorbent cotton spots, accounted for 34.8%, which was the highest percentage of HIV-related ophthalmopathy, with clear borders and no hemorrhage, and generally did not cause visual impairment or visual field defects. Retinitis accounts for 27.2% of cases. Fundus examination reveals typical retinal lesions, such as the presence of retinal vasculitis, hemorrhage, massive exudation, irregular yellow-white granules, etc., which may involve the macular area, but no clouding of the crystal; in old CMV retinitis, retinal hemorrhage may occur mechanically. 2 cases (2.2%) of patients present with total uveitis, vitreous clouding and vision loss due to immune reconstitution syndrome. In some AIDS patients with cryptococcal meningitis, increased intracranial pressure may lead to optic papilloedema and optic neuropathy in 5.4% of cases. 17 patients (18.5%) had chronic conjunctivitis on ophthalmologic examination; one patient with syphilis had a syphilitic rash on the skin and conjunctiva, and the pathology of the rash biopsy excluded lymphoma or Kaposi’s sarcoma. The syphilis rash gradually disappeared after 14 days of penicillin treatment.
Ninety-two patients with AIDS were also mixed with a variety of other multiple opportunistic sources of pathogenic infection or other complications.
Discussion.
HIV-associated ophthalmopathy is a common complication of AIDS and its incidence varies geographically, affecting 50-75% of HIV-infected patients in developed countries, CMV retinitis was found in 1% of patients in Malawi in sub-Saharan Africa, and HIV microangiopathy in 13%; Sophia et al. reported HIV-associated ophthalmopathy in 23.8% of Indian AIDS patients. In this study, a preliminary assessment of the clinical and epidemiological features of HIV-associated ophthalmopathy in Chinese AIDS patients showed that absorbent cotton spots were the most common HIV-associated ophthalmopathy, accounting for 34.8%, followed by retinitis, accounting for 27.2%, with cytomegalovirus retinitis being the most common. Retinal detachment and total uveitis due to immune reconstitution syndrome each accounted for 2.2%. HIV-related eye diseases, especially retinitis, retinal detachment and uveitis, can cause vision loss or even blindness in patients with AIDS, so early screening for HIV-related eye diseases is particularly important. In addition, in this study, we found that several ophthalmic lesions can coexist, most commonly absorbent cotton spots and uveitis together, and others such as retinitis or absorbent cotton spots and chronic conjunctivitis together.
In the group with or without HIV-associated ophthalmopathy, 56% and 46.5% had ophthalmic symptoms, respectively, and 44% and 47.6% had no ophthalmic symptoms, respectively, with no significant difference between the two. It is important to improve ophthalmologic examination, including fundoscopy, in all AIDS patients because if the injury occurs in the periphery of the retina, patients may not have ophthalmologic symptoms such as vision loss, visual field defects, blurred vision, or floating objects in front of the eyes. After the emergence of immune reconstitution syndrome, the existing retinal damage expands to appear as visual impairment.
HIV-associated ophthalmopathy, which often occurs in patients with CD4+ T lymphocytes <100/ul, consists mainly of HIV-associated microangiopathy and retinitis. Retinitis is mainly caused by CMV infection, and its diagnosis is made by determining CMVemia, and secondly, fundus examination reveals typical retinal lesions, such as the presence of retinal vasculitis, hemorrhage, massive exudation, and irregular yellow-white granules, which can involve the macular area but no clouding of the crystal.Sophia et al. reported [5] that in CD4+ T lymphocytes below 100 cells/ul are an independent In the present study, we found a mean CD4+ T lymphocyte count of 87/ul in 50 patients with AIDS-related ophthalmopathy, which is similar to foreign reports. The mean CD4+ T lymphocytes in 42 patients without AIDS-related eye disease were three times higher than those in the AIDS-related eye disease group, suggesting that patients with AIDS-related eye disease had significantly lower CD4+ T lymphocytes; and AIDS-related eye disease was significantly increased in patients with CD4+ T lymphocytes below 100/ul.
Among the 50 patients with clearly diagnosed AIDS-related ophthalmology, 22 did not show ophthalmic symptoms, suggesting that when CD4+ T lymphocytes were significantly lower, patients had already developed ophthalmic damage but could have no ophthalmic symptoms. Ophthalmic screening must be improved in patients with CD4+ T lymphocytes below 100/ul to detect AIDS-related eye disease early. In this study, there were 14 patients with CD4+ T lymphocytes below 50/ul, but no AIDS-related ophthalmology was detected, so cytomegalovirus infection was easily combined at this time.
HAART treatment gradually restores the number and function of CD4+ T cells and enhances the body’s immunity, but it can also lead to immune restorative uveitis, resulting in anterior uveitis and vitreous inflammation, causing macular cystoid edema and leading to blindness; the mechanism may be related to the inflammatory response to CMV antigen or low-level replication of CMV after the improvement of immune function. In this study, two patients were found to have immune reconstitution syndrome after HAART, leading to uveitis; therefore, one study suggested perfecting fundoscopy every 3 months in patients with immune recovery (CD4+ T lymphocytes >100/ul).
Tuberculosis within and outside the lungs is a common opportunistic pathogenic infection in Chinese patients with AIDS. 28 cases of tuberculosis were identified in this study, but there was no significant difference in the occurrence of AIDS-related ophthalmopathy with tuberculosis.
Some patients complained of floating objects in front of the eyes, but ophthalmologic examination only suggested chronic conjunctivitis, and 17 cases of chronic conjunctivitis were found in this study. In addition, in this study, we found a patient with AIDS combined with active syphilis who had a scattered red rash around the body and a conjunctival occupying lesion, with an RPR of 1:32. The pathology of the rash excluded lymphoma and Kapozi’s sarcoma, and the rash and conjunctival occupying lesion disappeared after treatment with penicillin for syphilis.
Among them, cytomegalovirus caused retinitis in 39 cases. Cytomegalovirus can cause retinopathy, and immune reconstitution syndrome after ART treatment can lead to retinopathy. Among the 39 patients only 25 patients developed CMV retinitis and 5 of them were blinded, so patients with AIDS should improve their ophthalmologic examination and be treated with active anti-CMV therapy. In this study, 15 cases of cryptococcal meningitis were found, and cryptencephalus can cause intracranial pressure elevation to compress the optic nerve and retina, leading to optic nerve atrophy and optic papillary edema; therefore, anti-cryptococcal and intracranial pressure reduction therapy should be intensified.
In conclusion, among the 92 AIDS patients in this study, HIV microangiopathy was the predominant AIDS-related ophthalmopathy (34.8%), followed by retinitis (27.5%), and different ophthalmic lesions can coexist; ophthalmic symptoms in AIDS patients are not diagnostic criteria for HIV-related ophthalmopathy, and routine ophthalmic screening must be improved for patients with CD4+ T lymphocytes below 100/ul